Provider Demographics
NPI:1386825396
Name:GILLIAM, TAMMIE RENEE
Entity Type:Individual
Prefix:
First Name:TAMMIE
Middle Name:RENEE
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 EAST SULLIVAN ST
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660
Mailing Address - Country:US
Mailing Address - Phone:423-224-1620
Mailing Address - Fax:423-224-1640
Practice Address - Street 1:1041 EAST SULLIVAN ST
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660
Practice Address - Country:US
Practice Address - Phone:423-224-1620
Practice Address - Fax:423-224-1640
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000112103163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3911774Medicare PIN
TNB58933Medicare UPIN